Exemplary Professional Practice

Encouraging words to patients declining bed and chair alarms made the difference for Med-Surg care team members on 10 Orange at UTSW’s Clements University Hospital. Ambulation with assistance after a procedure is important for the patient’s recovery. Often patients believe they don’t need help getting from the bed to a chair or from a chair to the bathroom, so they decline the assistance that’s available with the push of a button. Previously, staff members were unsure what to say to ensure patients would consistently and confidently use the alarms. Nurse managers used staff meetings to explain the importance of family teaching and re-educating each patient and family on the importance of the alarms every shift. In addition, managers suggested using language that would not be intimidating to patients and implemented use of the phrases daily for about a month during quick hits. For example, when nurses responded to an alarm, they entered the patient’s room, asking, “What can we do for you?” – a simple query of friendly assistance. If the patient declined the alarm, nurses explained that the alarm is not a restraint and that the patient can get up anytime but also that staff would respond quickly to assist them if/when the alarm goes off. An escalation flow chart was created, and all staff were instructed in its use in the event a patient continued to decline the alarm. The goal of this initiative was for our unit’s fall rate to be less than 2.1. Prior to implementation, our fall rate average was 3.32. After our implementation of the escalation tree and everyone utilizing the same, less-intimidating language with patients, our average is now 2.1.

As COVID-19 care ramped up in the fall of 2021 and ancillary staff was brought back into the mix of caring for COVID patients, communication with nursing staff became more complex. Because of the necessary use of N95s, PAPRs, and other PPE, nurses were unable to use WL3 phones in COVID rooms, and the Vocera wireless voice communication tool was still relatively new technology. Feedback from nurses indicated that communication through transitions was their biggest challenge. It became a team goal to improve communication and response time to staff needs while inside a COVID patient room.

One suggestion for meeting that goal was to use the chat function available in Epic, UTSW’s electronic medical record application. Initially, different group chats were created in Epic for each shift to include groups of buddy nurses, their PCT, their RN runner (when present), the charge nurse, and the HUC. This allowed primary nurses in COVID rooms to ask for help to a group of people outside the room and get assistance from whoever was readily available. When COVID numbers declined as 2021 progressed, the process was updated to have one Epic chat for the whole unit, with all RNs, PCTs, the charge nurse, and HUC in the COVID area included together rather than separately. Using this chat function made communication more efficient and decreased the need for RNs and PCTs to leave the room for requested items, saving doffing and donning of PPE and overall time. Feedback from leadership rounding with staff indicated increased satisfaction with communication and teamwork from using the Epic chat function.

Infusing Hope: Implementing a Monoclonal Antibody Infusion Therapy Pathway for COVID-19 Patients

In November of 2020, some nine months after COVID-19 was first detected in the United States, monoclonal antibody infusions such as bamlanivimab were identified as an effective treatment for more severe cases of SARS-CoV-2 and were given Emergency Use Authorization (EUA) by the U.S. Food and Drug Administration (FDA). At UTSW, ambulatory nursing leadership was tasked with collaborating with Pharmacy Services, Infection Prevention, Supply Chain Management, Information Resources (IR), Facilities, and the Epic training team to create an infusion area that could provide biologic infusion services for actively symptomatic COVID-19 patients meeting the medical criteria for treatment. Thus, the COVID Infusion Clinic was opened within a space originally created for COVID-19 testing with the help of our COVID Readiness team, which included staff from Ambulatory Nursing Operations.

The goal of the initiative was to provide biologic infusion therapy to patients who were high risk for progressing to severe COVID-19. We aimed to do so in a safe environment that reduced the risks of endangering staff or other healthy patients on campus and to decrease the risk of positive COVID-19 patient admissions via the Emergency Department.

One challenge to accomplishing these goals was the need to identify a clinical area isolated from common patient and staff access, while also meeting the logistical and engineering specifications of needing a negative-pressure space within the existing building. Additional challenges included identifying available support staff for patient scheduling and check-in, as well as to identifying available infusion-trained and certified RNs to administer the infusions to patients. Coordination of additional tasks included identifying necessary supplies, determining the clinical workflow, creating a scheduling template, and creating a staff schedule template based on seven day-a-week, eight-hour-a-day operations. Collaboration continued as education and training needs were identified, including PAPR training for all clinical staff. Additionally, Pharmacy and Logistics leadership were tasked with ensuring the workflow for drug mixing and delivery coincided with the infusion clinic workflows. As a result of this initiative, over the past 12 months more than 750 SARS-CoV-2-positive patients have received, and continue to receive, treatment with monoclonal antibody infusions.

New Building, New Plans for 8 Orange Epilepsy Monitoring Unit

Prior to the move from Zale Lipshy Pavilion to William P. Clements Jr. University Hospital, the Epilepsy Monitoring Unit team was informed that due to the distance between the pharmacy and the new location there might be a delay in getting some of the IV anti-seizure medication to the bedside if a patient went into status epilepticus, a seizure lasting more than five minutes. This was disheartening news for the EMU APPs because they had recently completed a QI project with the Zale pharmacy on improving delivery time of these medications; nevertheless, they knew they’d need to identify a solution in order to provide their patients with the best possible care.

The EMU APPs conducted a literature review and compiled a list of evidence-based rescue medications for patients in status epilepticus. They then reviewed the list with the EMU Medical Director and a pharmacist to determine which medications could be kept in the unit’s Pyxis station and used as first-line rescue for patients in status epilepticus while the pharmacy was mixing and delivering the second- and third-line medications. It was determined that levetiracetam (Keppra) could be stocked in the Pyxis and used in instances when a patient’s seizures were refractory to lorazepam. This request was then taken to the hospital pharmacy committee for review and approved. By Feb. 1, 2021, all stakeholders and committees had approved the request. The APPs then collaborated with the new EMU Nurse Manager to ensure all bedside nurses received notification of the change and education on administering the levetiracetam IV push. The EMU seizure rescue order set was also updated in Epic.

As a result of the team’s efforts, there has not been a single instance of a delay in medication administration in a patient with status epilepticus. The nurses are able to retrieve both lorazepam and levetiracetam from the Pyxis and administer them while the pharmacy is mixing and delivering second- and third-line rescue medications. Alleviating seizures as quickly as possible is imperative in patients with status epilepticus. Because of this team’s diligent efforts, patients have received high-quality, evidence-based care that has kept them from being intubated and transferred to the ICU and improved their overall outcomes.

After-Hours Telephone Triage Nursing

Because COVID-19 pandemic restrictions resulted in limited ability for in-person meetings and staff celebrations, leaders in the General Internal Medicine (GIM) Clinic wished to enhance opportunities for team-building and promotion of employee satisfaction and wellness. To accomplish this, they created what has been dubbed the “Sunshine Committee.” The specific goal was to bring together the clinic’s “work family” by hosting encouraging team-building activities (one example: a Halloween holiday decorating contest that accommodated COVID-19 meeting restrictions), recognizing employee birthdays, and celebrating staff members’ “wows and wins.”

Development of the GIM Sunshine Committee has increased opportunities for staff recognition. As COVID-related in-person meeting restrictions move toward less restriction, the committee plans to continue with future team-building and recognition events to keep up positive morale.